A 58-year-old female is admitted for a work up for a complaint of neck and low back pain. During admission, you discover that she underwent a renal transplant six years ago. The patient also had blood work collected. When you review the findings, you notice that her serum calcium is elevated at 13.9 (Normal values range from 8.5 to 10.2 mg/dl), her CBC shows a hematocrit of 33%, and hemoglobin of 11.1 g/dl (normal adult female hematocrit Range: 37-47%, normal adult female hemoglobin range: 12-16 g/dl). What does this mean and what could be the underlying cause of her pain and her abnormal lab values? What other assessments would be helpful?
The first thing that I would address is how she is doing with her anti-rejection medications and when the last time she followed up with her transplant team. Although the rate of rejection decreases every year after a transplant, the long term success of a kidney transplant significantly depends on regular follow up care with the transplant team, taking anti-rejection medications, and following the advice/care plan that is set in place for you (Kimberley, 2017). The fact that she is having that lower back pain concerns me of some type of kidney issue that can be as minor as a kidney stone or as severe as possible rejection. The elevated calcium can be attributed to many different things. It can be from overactive parathyroid glands, cancer, and a whole list of other things. I am suspecting that this patient could possibly be dehydrated because hypercalcemia can also be attributed to severe dehydration, which is also why my main concern is what is going on with her kidneys (Lumachi, 2010). Having a low hematocrit means that the percentage of red blood cells is lower what is expected. The patient can have some kind of internal bleeding, or possibly even cancer. She has been on the anti-rejection medications for 6 years. A side effect of those anti-rejection medications is a secondary cancer. It wouldn’t hurt to have that evaluated. A lower hemoglobin can also be indicative of chronic kidney disease, and/or cancer (Kimberley, 2017).
I would recommend that an entire kidney workup be completed for this patient. That would incredude a complete metabolic panel, a UA, Renal US. It is possible that this is just a kidney stone, but that is where I would start. If all those prove to be normal then I would do a cancer workup to see if it is possible the patient has developed a secondary cancer from the anti-rejection medications. If that proves not to be the problem then I would consider maybe with the patients age that this could be indicative to osteoporosis.
